Friday, January 27, 2006

Disturbing Case

I nearly missed this news article, which is too lengthy to reproduce in full. Here are the opening paragraphs and the accompanying commentaries by some lawyers.A First: Doctors applied to court for permission to amputate patient's legs as she was in coma A Twist: Order cannot be carried out as patient wakes upBy Karen WongJanuary 26, 2006IT is a legal first that comes with a medical twist.The High Court has handed down an unusual order to allow doctors to amputate a diabetic patient's legs in order to save her life.The order was sought by the woman's doctors because she was in a coma and her only kin here, her 16-year-old son, was too young to sign the consent papers.Earlier, she would not agree to the amputation.And here's the twist: after the court passed the order, but before the operation could be carried out, the 51-year-old woman woke up from her coma.Now, as long as she remains lucid, doctors have to keep aside the court order and go by her wishes. Lawyers: Case is significantTHIS is the first time that a hospital here has gone to court seeking such a declaration.And, the court's landmark decision means that in future, doctors may not need to go running to court for such a declaration, when faced with a similar situation, lawyers say.When contacted by The New Paper last night, Ms Kuah Boon Theng, a lawyer who advises doctors and hospitals, commented: 'We now know that Singapore has adopted the English law position, which is that in situations where a patient is not competent to decide, and when the procedure is in their best interest, doctors can proceed to provide the treatment.'What is the effect of this court judgment on doctors and hospitals?She said: 'In future, there may be no need for doctors to scurry to court every time they are faced with this same situation, to seek a court declaration.'When contacted, Mr Christopher Chong, the hospital's lawyer, commented: 'If a comatose patient has not previously said anything, this decision confirms that doctors would have to treat the patient according to the best interest of the patient medically.'But in unusual cases where there is uncertainty as to the patient's consent, there is now a procedure by which the lawfulness of the proposed treatment can be determined by the court.'Although it remains to be seen whether the amputation will be performed in Madam LP's case, lawyers seem to be unanimous in saying that Justice Choo Han Teck's ruling will be relevant in similar medical cases.Now you may think that angry doc will be jubilant at the fact that the court has essentially ruled that 'doctors know best', but I am actually very disturbed by the ruling. Again, it is difficult to judge what the doctors did with just the information provided in the article; the doctors who did what they did must have their reasons, but it seems to me this case violates the concept of patient autonomy.I have previously been in medical teams managing patients whose lives were threatened by a gangrenous limb or perforated gut, but who refused life-saving surgery.It was frustrating to watch them deteriorate day by day and sink into a febrile delirium when you know that we have the means to save the patient's life and all we needed was for him or her to say 'yes'. Sometimes they changed their minds. Sometimes it was too late by the time they changed their minds.But we never forced the issue. We knew that just because the doctor knew best, it didn't give him to right to do what he thought was best.I think this court ruling actually made it harder for doctors from now on, rather of easier.Will the doctor who genuinely wants to respect the wishes of a patient face a lawsuit from the patient's family if he would not apply a court order to over-rule the patient?Will the doctor really be immune from a lawsuit from the patient who lived because of the court order, but now suffers 'a fate worse than death'?How will you feel if you wake up from a coma to find a part of yourself removed against your expressed wish? Will you ever be able to trust your doctor again?

26 Comments:

Just wondering if the doctor is allowed to do what he feels is the best way to "save life", actually does more harm than good.

In an age of doctors with variable/questionable skills and competence,public hospitals allowing junior medical(nonspecialist) officers without adequate training/experience to run almost the entire show.

There are many poor decisions made with the patients best interest in mind.

There are too many people involved in the decision making process now.

It should really just be the doctor and the patient and the relatives.

What the court could have done is rule that in extraordinary cases like this, they can appoint another next-of-kin, or close friend to be the legal consent giver instead of leaving this to the doctors.

Makes more sense to me. I don't think it is fair to place this heavy burden on the doctor to decide what the patient's wishes are and at the same time be the one recommending what treatment to undertake. In a way there is a "conflict of interest" there. What if the patient had no intention to survive the gangrene? And as she had said "would rather die than lose her leg".

Evidently, from her decision after she awoke from her coma, she did NOT want to live.

We always assume patients want to live whatever the cost. This is not true in my experience.

Isn't this an abuse of legal process and a serious lapse in medical ethics?

If the newspaper reporting is accurate, the patient had already expressed her wishes to preserve her legs at all costs, in that she would rather die than to lose her legs, then, unless the patient was of unsound mind due to psychiatric or medical causes when the decision was made, the patient's autonomy should have been respected at all costs.

The doctors should NOT have tried to circumvent her wishes by obtaining "consent" from her son, or from the courts.

Ethically, how can this consent ever be valid? How could the judge allow the court order to go through?!

What happened to informed consent? Did the doctors, medical social worker, hospital lawyer and whoever else were present counsel her properly BEFORE she into a coma?

As the lawyers say, this case is significant indeed.

As angrydr had rightly pointed out, this is indeed a mockery of patient autonomy; a slippery slope the medico-legal fraternity has now tread.

Will we come to a time when the courts have more basis over our bodies than ourselves? Informed consent no longer necessary - I now have a legal process to do whatever I wish to your body, even if there's a possibility that you may live in agony for the rest of your life, and that you will have to sell your sons & daughters to child prostitute syndicates just to fund your medical care.

Would the courts like to pay the bill for her prosthetic limb, her diabetic medications, her future hospitalisations for DKA/HHNK, her renal dialysis when she goes into nephropathy, her photocoagulation therapy for her retinopathy and so on?

Perhaps she had taken huge insurance policies, and her son will benefit. Who knows.

It seems that the court decision here was made on a technicality: that there is no record of the patient having refused the surgery.

So now it's no longer enough to give explicit consent for procedures you will undergo, but you must also state explicitly (and have it recorded) that you refuse such and such procedures?

It is equally easy to argue that a patient is 'not in the best state of mind' when he or she refused a procedure, since presumably no one close to death would be (although one can safely be allowed to consent to a procedure in the same state...).

I'd better go to a tattoo parlour this weekend to have 'Do not remove under penalty of law' tattooed onto my various favourite appendages...

In such case that the doctors did not write down that the patient had refused surgery even if that led to (un)favourable circumstances, the doctors should be severely reprimanded for non-contemporaneous medical records,not only legally, but also with the rod of medical ethics.

What sort of example is this going to set for future generations of doctors? Surely the medical profession has progressed from the archaic times?

This incident has cast much doubt upon the integrity of the medical profession in general. Ethics have gone awry.

It is unfortunate and disturbing that I and numerous other junior doctors have to live with this.

On the other hand, if a patient is unconscious and we as doctors don't act, is that correct?

For example, if a patient is in a diabetic coma or unconscious following a drug overdose, techinically they cannot consent to life-saving treatment, with would be administration of a simple infusion or antidote.

It may not be as drastic as limb removal, but we should still treat them even though they are unconscious.

gsmo: It's difficult to say whether or not she was mentally competent, isn't it? You could argue that a patient who was sick enough to lapse into a coma would be too delirious to be able to make an informed decision.

Actually, in the end, I think most doctors would tend to perform life-saving treatment in the absence of any written advance directive. If the patient survives to scold us for doing what doctors are trained to do, then it's a very unfortunate thing.

The reason why this case is unique is because the next of kin is a 16 year old.

Frankly this situation is not common. But I find it hard to believe this lady has no other relatives aged >21 years old?

In most instances we have next of kin, family etc to consult and discuss options with. In a way the decision is thought through and made by a few individuals and thus responsibility is shared.

I'm for proposing that instead of the court ordering the doctors the sole decision makers in such instances, to allow other next of kin (perhaps distant or even <21yrs old) or close friends/acquaintances etc to serve the function of the "next of kin".

This would restore the situation to what is usually the norm rather than change it so drastically.

To gsmo, challenging times call for equally challenging measures. I have always felt that the consent forms we get patients to sign should contain EVERY SINGLE potential complication and problem that may be possible even if it numbers into several pages of fine print. In every other contract be it when you buy a house, a car, get a loan, etc there is always all this fine print which not everyone reads. Yet it is legally binding because you signed it.

The solution is simple. As a doctor I have several consent forms for all the possible operations drawn up with the assistance of lawyers. When I feel the patient should have X operation, I'll tell her and get her to read and sign the form and ask for any clarifications if she needs. At the same time I will highlight the main important points. This is standard practice with any other contract anyway. I don't think the insurance agent explained every single point on the contract to me.

And if the patient agrees to the operation/procedure, she signs in the "I agree to give consent" column. If not, she signs in the " I DO NOT give consent and choose not to have the operation/procedure" column.

It is high time we fought these legal problems legally rather than giving justifications medically. At the end of the day, the legal issues have come into our practices whether we like it or not, and they are here to stay. We should adopt legal protection as well.

Having a lawyer around would be great. Patients abuse you can sue them for assault! The lawyer would also be responsible for the legal side of things. Lessens the burden on the doctor having to negotatiate all these mindfields. We should just be focusing on medicine.

Cost for the lawyer? Simply pass it on to the patients.

Now you see why it would never happen? It has nothing to do with whether it is good or not for medicine. In my opinion it is all for the good. It has everything to do with cost. And the people want their cake and eat it.

tscd: Most reasonably competent medical professionals who suspect that the patient was not mentally or medically competent to give consent would check whether the patient was alert, oriented through basic questions on time, place, person and perhaps some general knowledge, or with the assistance of a psychiatrist.

Granted, most doctors would institute heroic measures to save lives in the absence of an AMD. What is particularly glaring and deplorable in this case was that the patient had already refused surgery.

drozbloke: I agree with you on the part of consent forms, but our medicolegal protection must be tempered by the potential impact on the doctor-patient relationship. An entire list of postoperative complications from the pre-operative, intra-operative and post-operative period may be too frightfully daunting and deter the patient from surgery. From the legal standpoint, even the rarest but most significant complication must be explicitly explained, but surgery is a calculated "gamble", weighing the risks vs. benefits.

Unfortunately, it is readily apparent that the legal fraternity lags behind medical ethics and norms.

Ultimately, as professionals, we should try our best to be governed by our own professional body of ethics, and not to be unduly influenced by legal implications - all of which are extremely hard to do in the current hostile climate.

A disturbing case, indeed. Of course, the medical community needs attorneys. However, using attorneys in the decision-making process will cause fewer doctors to enjoy their work, I believe. I agree with dr. oz bloke: "Too many cooks spoil the broth."

When you're in the dock and facing the lawyer, can you say things like "An entire list of postoperative complications from the pre-operative, intra-operative and post-operative period may be too frightfully daunting and deter the patient from surgery. From the legal standpoint, even the rarest but most significant complication must be explicitly explained, but surgery is a calculated "gamble", weighing the risks vs. benefits.

Unfortunately, it is readily apparent that the legal fraternity lags behind medical ethics and norms." and get away with it? I doubt the courts and legal systems work like that.

Hence we are really at the mercy of the courts on their terms, which is primarily legal in nature. And judging from past cases, they aren't buying it.

The law is the law. And doctors are in reailty not exempt from it no matter how we justify it.

dr oz bloke: That advice was actually doled out to local junior staff by a few "famous" lawyers with an interest in medico-legal issues.

Having said that, I do not suggest anyone try to contest the law from the standpoint of ethics without advice from an excellent lawyer.

You can look up a few books on medical ethics & law - there are a number of examples in which the law was changed because doctors treated their patients ethically (and with assistance from exceptional lawyers), e.g. OCP and underage children, age of consent, abortion, etc.

The point here is the law is the law and lawyers are the expert professionals as far as it is concerned. You wouldn't ask a lawyer interested in medicine to give you medical advice based on a couple of books he's read would you?

Just in today's papers there is an article about how stem cell researchers won't proceed until the law is laid down.

I don't bother reading ethics books. Ethics vary from country to country, culture to culture, individual to individual. But the law applies to everyone (at least that's the intention).

I know that I can be irrational at times, but I not only expect, I insist that my advance care directives regarding medical treatment will be obeyed by my doctor(s) in the event I am unable to communicate those orders due to unconsciousness, anaesthesia or debility.

In most cases, I'm not being unreasonable, and I'm willing to listen to what a physician has to suggest. Well, willing to listen as long as it doesn't involve giving me opiates (I hate them because they make me vomit) or new procedures just for the sake of novelty.

However, if I choose to end my life by refusing treatment for an infection, that's my choice and I expect that choice to be heeded. I wouldn't make that choice unless I had other reasons, such as not wanting to continue a series of ultimately pointless and painful treatments, or facing the rest of my life miserable and exhausted.

Living just for the sake of living isn't always worth it. Usually it is, but there are cases where it's just time to let things come to an end.

What's more, I expect my advance care directive to be obeyed even if a physician deems me mentally ill and/or depressed. It's my own business whether I'm depressed or not. Perhaps I don't want to deal with THAT any longer, either.

I suppose I might be a lot gentler on physicians if I didn't work in basic life science research in a medical school polluted with arrogant little gits (aka medical students) who don't want to learn anything that won't be on the exam. I wouldn't be as hard on physicians if they knew their physiology and pharmacology better. I expect a physician to know what he or she is prescribing, how it works, what class of drug it belongs in, what major interactions are possible, and what it's for. After all, I know they have to take those classes as medical students. I expect them to retain the material.